Not Medically Necessary - Denied Home Monitoring System - seeking advice

[Sean75GB]

Hey there,

Just received my denial letter from my insurance company pertaining to my PT/INR home monitoring equipment. The 4 criteria points they are saying it does not meet are the following:

1) Substantiated by clinical documentation;
2) The most appropriate and cost effective level of care, compared to other levels of intervention, including no intervention, which can safely by provided by the covered person. Appropriate and cost effective does not necessarily mean the lowest price.
3) Proven to be useful, likely to be successful, yield additional information, or to improve clinical outcome; and
4) Not primarily for the convenience or preference of the covered person, his or her family, or any provider.

Does anyone have any suggestions as far as information I can use if I file an appeal. Are there official studies out there that would help me make a case to overturn? FYI, (37 yr old male) I had an aortic valve replacement (mechanical) and aneurysm root repair (graft) on 2/24/12. Had a bicuspid aortic valve with severe regurgitation and aortic aneurysm. I'm on warfarin and still being checked weekly. Any suggestions would be greatly greatly appreciated. Thanks!!!

Sean

 

[AgilityDog]

Yes. Check our stickies in the anticoagulation forum for links to research.
home monitoring has been proven much more effective than clinics.
Medicare approves and pays for home monitoring.

If all else fails, and you have the $$, buy your own damn machine and strips and ignore the insurance company. After all, depending upon your policy, coverage, and deductible, you may wind up paying for the machine 10 times over if you are required to pay for Philips or Alere's monitoring service. Lord knows I paid for it 3 times in 2 years, before I just bought my own.

 

[dhudson]

Maybe your Doctor can get involved here and write a letter. I wonder, if the doctor made it a prescription how that would fly?? Just a thought ou of thin air! I know my doctor would help me deal with the insurance. Got to be cheaper than going to the clinic every week to be tested!!

 

[Sherryl]

I, too, battled with BCBS beginning in March 2007 for a home-monitoring machine. The reason for denial was like yours---a convenience item. I became quite upset & fired back a letter of appeal stating that: 1.) "Convenience" would be sitting on my behind 3 mornings a week instead of going to the gym for cardio & weight workouts in an effort to prevent future health problems/conditions for which BCBS would ultimately be responsible for in paid-our benefits. 2.) "Convenience" would be consuming the high-caloric foods I desire instead of daily monitoring my food intake of healthy foods & also being a lifetime Weight Wathcer member. By controlling my weight, I am at less risk for developing diabetes & other overweight complications which would result in high medical costs to BCBS.

BCBS DID approve my appeal. However, because I was going on a 34-day trip to Europe in April of 2007, I purchased my InRatio. When I returned, BCBS reimbursed me for only a portion of the amount I paid for the meter. I guess their contracted amount was less than what I paid. Because I was disgusted with the way BCBS handled the matter, I used my meter only when I was on vacation & continued going to the Coumadin Clinic until about 6 months ago. I am now on Medicare so they pay for the testing strips & supplies.

You are welcome to use the reasons I used in my appeal. If those 2 "convenience" reasons apply to you, feel free to use them.

Best Wishes,
Sherryl

ATS Aortic Valve Nov., 2005
Annuloplasty ring, Mitral Valve, Nov., 2005

 

[AgilityDog]

"convenience" means not losing 2-3 hours from work every week to go to the clinic (which doesn't open until 8:30, and there's usually a wait even then) plus getting instant results, instead of waiting 3 days, by when the results are USELESS.

 

[DanielB]

I'd certainly look into this further. I was rejected by my insurance company after first asking, then, after I went back to them and had them look into it, they agreed they had made a wrong decision and that someone in the process had put the wrong code on the paperwork. It took me a few weeks to get everyone on the same page, but I do have a new machine in hand. Also, when asked why I felt I needed one, I told them I travel a lot and have a busy job -- both making it really difficult to make time to go to a lab on a regular basis. That seemed to help the process along.

Good luck!

 

[Protimenow]

You might also point out that having a meter available will allow you to test more often than at a lab, and be better able to keep your INR in range than the monthly testing that labs seem to want to run. Staying in range - and knowing that you ARE in range every week - will potentially reduce your risk of hemorrhage or clot versus the inadequate (to my thinking) monthly testing at clinics.

This could reduce the insurance company's medical costs significantly (it's a lot cheaper to get you a machine and strips than it is to hospitalize you for stroke or excessive bleeding)